Week 3 Sherpath Flashcards by Monica Galvan-Valencia

Which characteristics are reflective of critical thinkers?

Select all that apply.

Aware of their personal biases

Open-minded

Impulsive

Listen well

Emotionally reactive

Aware of their personal biases

Open-minded

Listen well

How well did you know this?

Not at all

Perfectly

According to Paul and Elder, clinical thinking requires which components?

Select all that apply.

Emotion

Thought process

Reasoning

Intellectual standards

Intellectual traits

Thought process

Reasoning

Intellectual standards

Intellectual traits

How well did you know this?

Not at all

Perfectly

Match the intellectual standard associated with the Paul and Elder Framework with the descriptive question.

Do I have a bias that needs to be addressed?

Does the answer make sense?

Can the thought be proven correct?

Are more details necessary?

Answer choices

Significance

Precision

Logic

Accuracy

Fairness

Depth

Do I have a bias that needs to be addressed?
Fairness

Does the answer make sense?
Logic

Can the thought be proven correct?
Accuracy

Are more details necessary?
Precision

How well did you know this?

Not at all

Perfectly

Which description best corresponds to the term clinical judgment?

Used when discussing management scenarios or the reasoning process with nursing leadership

Requires recalling facts and recognizing patterns seen previously when caring for patients

Specific thought process used in nursing when analyzing, evaluating, and managing a patient

Similar to clinical reasoning but considered a broader term in nursing

Requires recalling facts and recognizing patterns seen previously when caring for patients

How well did you know this?

Not at all

Perfectly

According to Alfaro-LeFevre, which factors can affect a nurse’s ability to think critically?

Select all that apply.

Life experience

Self-confidence

Gender

Nursing role

Moral development

Life experience

Self-confidence

Moral development

How well did you know this?

Not at all

Perfectly

Which characteristic of both the nursing process and the Clinical Judgment Measurement Model refers to changes over time in response to patients’ individual needs?

Dynamic

Analytical

Organized

Adaptable

Dynamic

How well did you know this?

Not at all

Perfectly

Which activities would best promote critical thinking in nursing?

Select all that apply.

Asking a peer to clarify their thoughts when discussing a specific nursing situation

Creating a critique map for a complicated patient to provide visual representation of nursing care plans

The newly graduated registered nurse identifying an experienced coworker to have as a mentor

Writing about a specific patient experience and lessons learned from the experience

The nurse manager deciding the staff meeting should be scheduled on an as-needed basis

Asking a peer to clarify their thoughts when discussing a specific nursing situation

The newly graduated registered nurse identifying an experienced coworker to have as a mentor

Writing about a specific patient experience and lessons learned from the experience

How well did you know this?

Not at all

Perfectly

The nurse is caring for a patient who has been prescribed a blood transfusion after a traumatic injury. The nurse confirms it is the correct patient by reading his hospital wristband and verbally asking the patient his name and date of birth. The blood type is confirmed with a second nurse before initiation of the transfusion. This scenario is an example of which activity that enhances effective communication?

Situation, Background, Assessment, Recommendation (SBAR)

Time-out

Daily rounds

Concept map

Time-out

How well did you know this?

Not at all

Perfectly

Match the factor that hinders critical thinking with the correct description.

Not gathering all the facts before reaching a conclusion

Having an expectation of a result without selecting specific evidence

Jumping to conclusions; not clearly thinking through presented information

Believing the presented information is factual without validating first

Answer choices

Lack of information

Illogical thinking

Confirmation bias

Tunnel vision

Erroneous assumption

Close-mindedness

Not gathering all the facts before reaching a conclusion
Lack of information

Having an expectation of a result without selecting specific evidence
Tunnel vision

Jumping to conclusions; not clearly thinking through presented information
Illogical thinking

Believing the presented information is factual without validating first
Erroneous assumption

How well did you know this?

Not at all

Perfectly

The nurse is caring for a patient who is pregnant with her fifth child and considering terminating the pregnancy. The patient has asked the nurse for more information. For the past 2 years, the nurse has been unsuccessful in her own attempts to become pregnant. Which intellectual standard is the nurse most likely to have difficulty applying in this situation?

Humility

Empathy

Integrity

Perseverance

Empathy

How well did you know this?

Not at all

Perfectly

Critical thinking is a conscious decision not to accept something at face value and instead attempt to analyze it from all perspectives. Which actions are considered part of the critical-thinking process?

Select all that apply.

Identifying the concern

Determining which information is most relevant

Gathering the input of others

Vetting the information presented

Quickly determining a resolution

Identifying the concern

Determining which information is most relevant

Gathering the input of others

Vetting the information presented

How well did you know this?

Not at all

Perfectly

Match the intellectual standard with the scenario that represents it.

The nurse completely understands the complexities of the issue.

The nurse’s perspective has been confirmed as factual.

Others understand the nurse’s point of view.

The nurse focuses on the most important aspects of the situation.

Answer choices

Accuracy

Depth

Precision

Significance

Clarity

Breadth

The nurse completely understands the complexities of the issue.
Depth

The nurse’s perspective has been confirmed as factual.
Accuracy

Others understand the nurse’s point of view.
Clarity

The nurse focuses on the most important aspects of the situation.
Significance

How well did you know this?

Not at all

Perfectly

According to Alfaro-LeFevre, which individual should be most adept at thinking critically?

A 40-year-old man who has only lived in a small town and never traveled outside of his state

A 22-year-old woman whose father was in the military, requiring her to live in Germany, England, California, Florida, and Missouri

A 36-year-old person with high self-esteem and self-confidence

A 19-year-old freshman in college who is majoring in communication

A 22-year-old woman whose father was in the military, requiring her to live in Germany, England, California, Florida, and Missouri

How well did you know this?

Not at all

Perfectly

Which actions demonstrate a nurse using the Clinical Judgment Measurement Model (CJMM) and critical thinking when a patient reports increased pain at the surgical site?

Select all that apply.

Verifying that no pain medications were prescribed after surgery and calling the health care provider to inform them of the patient’s change in status to see if pain medications can be given

Determining whether pain medications were prescribed postoperatively, then compassionately relaying to the patient that no pain medications were prescribed for them

Using nonpharmaceutical treatment of focused deep breathing and imagery to help relieve the patient of pain after verifying that no pain medications were prescribed

Assessing the patient’s vital signs and verifying which pain medications were prescribed and when pain medication was last given to the patient

Assessing the surgical site to determine whether infection could be the cause of increased pain

Verifying that no pain medications were prescribed after surgery and calling the health care provider to inform them of the patient’s change in status to see if pain medications can be given

Using nonpharmaceutical treatment of focused deep breathing and imagery to help relieve the patient of pain after verifying that no pain medications were prescribed

Assessing the patient’s vital signs and verifying which pain medications were prescribed and when pain medication was last given to the patient

Assessing the surgical site to determine whether infection could be the cause of increased pain

How well did you know this?

Not at all

Perfectly

Match the description of the nurse with the appropriate career stage.

A nurse with 3 years of experience, who just started working in the ICU

A nurse with 18 months of experience in the cardiac step-down unit

The charge nurse in the neonatal ICU

The neurosurgery unit staff educator nurse

Answer choices

Competent

Novice

Advanced beginner

Proficient

Expert

A nurse with 3 years of experience, who just started working in the ICU
Novice

A nurse with 18 months of experience in the cardiac step-down unit
Advanced beginner

The charge nurse in the neonatal ICU
Proficient

The neurosurgery unit staff educator nurse
Expert

How well did you know this?

Not at all

Perfectly

An experienced nurse, who is precepting a new nurse, is caring for a critically ill patient and just placed a feeding tube as prescribed. After auscultation of air into the stomach to confirm tube placement, the preceptor initiates the tube feeding. The new nurse questions the starting of feeds without verifying nasogastric (NG) tube placement by x-ray, which is the new standard of care. The preceptor responds, “I have been a nurse for 20 years, and I have always verified placement by auscultation of air into the stomach.” This response is an example of which activity that can hinder critical thinking?

Bias

Erroneous assumption

Illogical thinking

Close-mindedness

How well did you know this?

Not at all

Perfectly

The emergency department (ED) nurse is handing off care of a patient to the intensive care unit (ICU) nurse. The ED nurse is giving report using the Situation, Background, Assessment, Recommendation (SBAR) method. The ED nurse tells the ICU nurse that the patient is admitted for respiratory distress and is currently homeless. Which SBAR communication element does this scenario represent?

Situation

Background

Assessment

Recommendation

Background

How well did you know this?

Not at all

Perfectly

Match the clinical reasoning process with its descriptor.

Recognizing the detail that is most important in the scenario

Identifying which tasks are most important and should be performed first

Identifying which tasks can be delegated

Recognizing that the action is necessary and professional

Answer choices

Right reason

Right expertise

Right patient

Right action

Right time

Right cue

Recognizing the detail that is most important in the scenario
Right cue

Identifying which tasks are most important and should be performed first
Right time

Identifying which tasks can be delegated
Right action

Recognizing that the action is necessary and professional
Right reason

How well did you know this?

Not at all

Perfectly

Which nursing skill is essential to utilize throughout the nursing process?

Analysis

Observation

Critical thinking

Time management

Critical thinking

How well did you know this?

Not at all

Perfectly

Place the steps of the nursing process in the order in which each should occur.

Evaluation

Implementation

Analysis

Planning

Assessment

Analysis

Planning

Implementation

Evaluation

How well did you know this?

Not at all

Perfectly

Match the nursing process characteristic to its description.

The nursing process incorporates the interprofessional team.

Nurses evaluate patient results to determine effectiveness.

Nurses use critical thinking for each step of the nursing process.

The nursing process helps ensure that patient care is well planned.

Answer Choices

Collaborative

Organized

Outcome-oriented

Analytical

The nursing process incorporates the interprofessional team.
Collaborative

Nurses evaluate patient results to determine effectiveness.
Outcome-oriented

Nurses use critical thinking for each step of the nursing process.
Analytical

The nursing process helps ensure that patient care is well planned.
Organized

How well did you know this?

Not at all

Perfectly

Which component determines whether an assessment is primary or secondary?

Source of data

Types of data

Categories of data

Objectivity of the data

Source of data

How well did you know this?

Not at all

Perfectly

Match the category of data with its description.

Obtained directly from patient

Blood pressure reading and weight

Direct quotes describing patient feelings

Obtained from other health care professionals or medical records

Answer Choices

Objective

Subjective

Secondary

Primary

Obtained directly from patient
Primary

Blood pressure reading and weight
Objective

Direct quotes describing patient feelings
Subjective

Obtained from other health care professionals or medical records
Secondary

How well did you know this?

Not at all

Perfectly

Which examples reflect subjective data?

Select all that apply.

Signs

Feelings

Symptoms

Perceptions

Laboratory findings

Health history

Feelings

Symptoms

Perceptions

Health history

How well did you know this?

Not at all

Perfectly

Which nursing concept is defined as an actual or potential problem or response to a problem? Plan Outcome Diagnosis Assessment

Diagnosis

Which aspects do nurses make judgments about when determining initial nursing diagnoses? Select all that apply. Vulnerabilities Patient problems Health promotion Risk for problems Evaluative measures

Vulnerabilities Patient problems Health promotion Risk for problems

Which action reflects a primary task in the analysis step of the nursing process? Initiating nursing actions Forming diagnostic conclusions Identifying realistic patient goals Examining the effectiveness of interventions

Forming diagnostic conclusions

Which term describes how the nursing process changes over time in response to patients’ individual needs? Dynamic Analytical Organized Adaptable

Dynamic

Which statement defines collaborative interventions? Involve independent nursing interventions Establish the effectiveness of nursing actions Require a prescription from the health care provider Involve the expertise of health care team members

Involve the expertise of health care team members

Match the type of nursing intervention to the example. Patient positioning Foley catheter insertion Respiratory therapy consult Answer choices Independent Interdependent Dependent

Patient positioning Independent Foley catheter insertion Dependent Respiratory therapy consult Interdependent

Which function describes the primary purpose for documenting nursing interventions? Implement policy. Prove task completion. Facilitate communication. Ensure proper record-keeping.

Facilitate communication.

Which interventions reflect indirect nursing care? Select all that apply. Giving an injection Helping a patient ambulate in the hall Documenting medications administered Collaborating to schedule occupational therapy Working with a social worker to set up home care

Documenting medications administered Collaborating to schedule occupational therapy Working with a social worker to set up home care

During the implementation step of the nursing process, a nurse reviews and revises a patient’s plan of care. Place the steps of review and revision in the order in which each should occur. Review and revise the existing plan of care. Reassess the patient. Organize resources and care delivery. Implement nursing interventions. Anticipate and prevent complications.

Reassess the patient. Review and revise the existing plan of care. Organize resources and care delivery. Anticipate and prevent complications. Implement nursing interventions.

Which aspect would the nurse consider as a component of the evaluation step of the nursing process? The patient being discharged from the hospital The patient’s achievement of short- and long-term goals The nurse’s completion of interventions in the plan of care The nurse’s view on the patient’s desire to perform interventions

The patient’s achievement of short- and long-term goals

Which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process? Select all that apply. Recognizing errors Gathering patient cues Documenting patient progress Comparing achieved effect with goals Examining results according to clinical findings

Recognizing errors Comparing achieved effect with goals Examining results according to clinical findings

Which questions would the nurse ask when revising the plan of care because of unmet patient goals? Select all that apply. Were the original goals realistic? What unanticipated events occurred? Were the original goals collaborative? What steps in the process can be handled differently? What barriers did the patient encounter that prevented goal attainment?

Were the original goals realistic? What unanticipated events occurred? What steps in the process can be handled differently? What barriers did the patient encounter that prevented goal attainment?

Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care? Select all that apply. It is organized. It is outcome-oriented. It necessitates observation skills. It allows nurses to apply knowledge. It requires nurses to think analytically. It incorporates an interprofessional team.

It is organized. It is outcome-oriented. It allows nurses to apply knowledge. It requires nurses to think analytically. It incorporates an interprofessional team.

Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making? American Academy of Nursing National Student Nurses Association National League for Nursing American Nurses Association

American Nurses Association

Which questions are critical for the nurse to ask during each step in the nursing process? Select all that apply. Were patient goals met? Can interventions be universally applied? Is collected data thorough and accurate? Could interventions affect the patient negatively? Are all underlying factors addressed in the plan of care?

Is collected data thorough and accurate? Could interventions affect the patient negatively? Are all underlying factors addressed in the plan of care?

Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain? Analysis Evaluation Assessment Implementation

Assessment

Which type of data do the patient’s family members, friends, or other nurses provide? Primary Objective Secondary Comprehensive

Secondary

Which type of patient assessment takes into account all factors, such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health? General Holistic Focused Universal

Holistic

Which nursing action occurs during the analysis step of the nursing process? Initiating nursing interventions and treatments Identifying realistic goals that are patient-focused Clustering patient data to identify patient problems Gathering patient data through a variety of sources

Clustering patient data to identify patient problems

Which phrase describes the primary purpose of nursing analysis and diagnosis? Resolves patient confusion Communicates patient problems Articulates the nursing scope of practice Describes the medical context of the patient problem

Communicates patient problems

Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process? Select all that apply. Provides a standardized nursing language Outlines categories for patient information Categorizes priorities based on importance Identifies common labels for nursing diagnoses Provides point-of-care documentation for clinical activity

Provides a standardized nursing language Identifies common labels for nursing diagnoses Provides point-of-care documentation for clinical activity

During which step of the nursing process would the nurse prioritize nursing diagnoses? Planning Analysis Evaluation Assessment

Planning

During which step of the nursing process would the nurse establish long-term goals with the patient? Planning Analysis Evaluation Implementation

Planning

Which part of the nursing process involves the nurse setting short-term goals for the patient? Planning Diagnosis Evaluation Assessment

planning

Which step of the nursing process involves carrying out nursing actions designed to meet a patient’s unique needs? Planning Analysis Evaluation Implementation

Implementation

Which intervention reflects direct nursing care? Giving an injection Asking the health care provider to prescribe a special diet Documenting nursing interventions Working with a social worker to set up home care

Giving an injection

Which statements reflect the nurse’s role during the implementation step of the nursing process? Select all that apply. Be accountable for safe practice. Consult with the health care provider. Collaborate with support services. Perform the steps of intervention accurately. Understand why an intervention is planned.

Be accountable for safe practice. Perform the steps of intervention accurately. Understand why an intervention is planned.

Which step of the nursing process considers the effectiveness of nursing care? Planning Analysis Evaluation Implementation

Evaluation

Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care? Planning Evaluation Assessment Implementation

Evaluation

Which questions would the nurse ask to evaluate the effectiveness of nursing interventions? Select all that apply. Should the plan of care be discontinued? Which nursing diagnosis covers this cluster of signs and symptoms? Have new assessment data been identified that should be considered? Did the patient meet the goals established during the implementation phase? Does the plan of care need to be modified in response to patient changes?

Should the plan of care be discontinued? Have new assessment data been identified that should be considered? Does the plan of care need to be modified in response to patient changes?

Which data sources are examples of secondary data? Select all that apply. Patient chart Laboratory test results Statements made by the patient Information from another health care provider Statements made by a family member

Patient chart Laboratory test results Information from another health care provider Statements made by a family member

Which assessment cues have a subjective classification? Select all that apply. Nausea Headache Lesions on leg Facial grimacing Blood pressure 110/78 mm Hg

Nausea Headache

Match the type of patient cue organization model with its description. Reveals patterns of patient data that are often overlooked Begins with documentation of general health status Concentrates solely on physical aspects of a patient’s condition Answer choices Head-to-Toe Gordon’s Functional Health Patterns Body Systems

Reveals patterns of patient data that are often overlooked Gordon’s Functional Health Patterns Begins with documentation of general health status Head-to-Toe Concentrates solely on physical aspects of a patient’s condition Body Systems

Match the assessment strategy with its description. Assesses patient’s body systematically Collects demographic and medical data Uses sight, hearing, and smell to gather data Answer choices Patient interview Physical examination Observation

Assesses patient’s body systematically Physical examination Collects demographic and medical data Patient interview Uses sight, hearing, and smell to gather data Observation

Match the type of assessment with its description. Thorough interview, health history, and physical examination Assessment when there is a concern about the patient’s condition Very focused survey with rapid decisions to address immediate concerns Answer Choices Emergency Focused Comprehensive

Thorough interview, health history, and physical examination Comprehensive Assessment when there is a concern about the patient’s condition Focused Very focused survey with rapid decisions to address immediate concerns Emergency

Which examination room preparation is most important for the nurse to complete between patients in an outpatient clinic? Sterilize all surfaces of the examination table. Remove all garbage from the room. Ensure that the barrier paper is neat and unsoiled. Confirm the examination table surface is clean and has a fresh barrier in place.

Confirm the examination table surface is clean and has a fresh barrier in place.

Which actions would the nurse take to prepare the environment for the physical assessment? Select all that apply. Assess that equipment is working properly. Wash hands on entering the patient room. Open personal protective equipment (PPE) so it is ready to use when needed. Obtain a translator when a communication barrier exists. Explain when position changes will be needed during the assessment.

Assess that equipment is working properly. Wash hands on entering the patient room. Obtain a translator when a communication barrier exists. Explain when position changes will be needed during the assessment.

Which aspect of creating a therapeutic environment reflects the nurse’s approval of a patient’s request for a family member to remain in the room during the patient interview and physical assessment? Patient safety Personal needs Physical comfort Emotional comfort

Emotional comfort

Which type of examination requires the nurse to alter the traditional sequence of assessment techniques (inspection, palpation, percussion, and auscultation)? Cardiac Abdominal Respiratory Integumentary

Abdominal

Which senses does the nurse use during inspection? Select all that apply. Sight Taste Smell Touch Hearing

sight smell hearing

Which term describes subjective indications of a disease or a change in condition as perceived by the patient? Signs Symptoms Conditions Assessments

symptoms

Which concept describes the process in which the nurse collects information related to a patient problem by speaking with the patient? Focused assessment Objective data collection Subjective data collection Comprehensive assessment

Subjective data collection

Which model of data organization uses a holistic approach to the patient and potentially reveals data patterns the nurse might otherwise overlook? Medical Head-to-Toe Body Systems Gordon’s Functional Health Patterns

Gordon’s Functional Health Patterns

Which assessment would the nurse perform during the patient’s initial visit to a new health care provider? Brief Focused Emergency Comprehensive

Comprehensive

Which environmental strategies would the nurse implement to maximize a patient’s comfort during an interview and physical examination? Select all that apply. Dim room lighting. Reduce extra noise. Increase visual stimuli. Remove distracting items. Manage room temperature.

Reduce extra noise. Remove distracting items. Manage room temperature.

Which actions would the nurse take when greeting the patient? Select all that apply. Introduce self. Call the patient by name. Start the physical assessment. Explain the reason for the interview. Educate the patient on hand hygiene.

Introduce self. Call the patient by name. Explain the reason for the interview.

Which actions would the nurse take after completing the interview and physical examination? Select all that apply. Document collected data. Discuss what to expect next. Encourage the patient to ask questions. Place the call bell on the bedside table. Assist the patient to a comfortable position.

Document collected data. Discuss what to expect next. Encourage the patient to ask questions. Assist the patient to a comfortable position.

Place the assessment techniques in the order performed for assessing the abdomen. Inspection Percussion Palpation Auscultation

Inspection Auscultation Palpation Percussion

Which factors would the nurse consider before performing an inspection during a physical examination? Select all that apply. Ample lighting Available assistance Time available for the examination Cleaning of the patient’s hands Adequate exposure of anatomic surfaces

Ample lighting Available assistance Time available for the examination Adequate exposure of anatomic surfaces

Which types of abnormalities can the nurse identify when percussing the abdomen? Select all that apply. Gas Fluid Masses Organs Wounds

Gas Fluid Masses

Which techniques would the nurse utilize when assessing the integumentary system? Select all that apply. Palpation Inspection Percussion Auscultation Evaluation

Palpation Inspection

Match the skin assessment term to the appropriate description. Redness Yellow hue Lack of color Blue discoloration Answer choice Cyanosis Pallor Erythema Jaundice

Redness Erythema Yellow hue Jaundice Lack of color Pallor Blue discoloration Cyanosis

The nurse associates abnormalities of the skin, hair, or nails with potential disorders of which systems? Select all that apply. Cardiac Sensory Neurologic Respiratory Hematologic

Cardiac Respiratory Hematologic

Match the type of health history content being gathered by the nurse to the appropriate question. Have you ever had any allergic skin reactions to food, drugs, or plants? Have you observed changes in the consistency, color, or texture of your nails? Has anyone in your family ever had skin cancer? Answer choices Personal medical history Family medical history Current health

Have you ever had any allergic skin reactions to food, drugs, or plants? Personal medical history Have you observed changes in the consistency, color, or texture of your nails? Current health Has anyone in your family ever had skin cancer? Family medical history

Which techniques would the nurse use when assessing a patient’s head, eyes, ears, nose, and throat? Select all that apply. Palpation Inspection Evaluation Percussion Auscultation

Palpation Inspection Auscultation

Which instrument would the nurse use to assess the pupillary reflexes? Penlight Otoscope Reflex hammer Tongue blade

Penlight

Which anatomic structure would the nurse auscultate during the examination of the throat? Jugular veins Thyroid glands Carotid arteries Subclavian arteries

Carotid arteries

Which question would the nurse ask to gather health history information about the patient’s head and neck? Do you have a history of vertigo? Do you have a history of tonsillitis? Have you ever experienced dizziness? Have you experienced pain or discharge around your eyes?

Have you ever experienced dizziness?

Which assessment techniques would the nurse use during examination of the respiratory system? Select all that apply. Palpation Inspection Evaluation Percussion Auscultation

Palpation Inspection Auscultation

Which characteristics would the nurse assess while inspecting the chest during the respiratory system examination? Select all that apply. Shape Symmetry Tenderness Skin temperature Breathing pattern

Shape Symmetry Breathing pattern

Which assessment finding would the nurse expect when auscultating the lungs of a healthy adult? High-pitched, loud bronchovesicular sounds Low-pitched, soft sounds heard over the trachea Pursed-lip breathing by the patient during expiration High-pitched, loud sounds heard over the main stem bronchus

High-pitched, loud sounds heard over the main stem bronchus

Which physical assessment techniques would the nurse use during examination of the cardiac and peripheral vascular systems? Select all that apply. Palpation Inspection Interview Percussion Auscultation

Palpation Inspection Auscultation

Which signs would the nurse associate with arterial insufficiency? Select all that apply. Pallor Edema Paralysis Numbness Pulselessness

Pallor Paralysis Numbness Pulselessness

Which region would the nurse palpate to assess for aortic vibrations? Epigastric area Midaxillary area Midthoracic area Periumbilical area

Epigastric area

When collecting information about the patient’s current health status related to the cardiovascular system, which questions would the nurse ask? Select all that apply. Have you recently gained or lost weight? Are you experiencing chest pain? Do you have edema or swelling in your ankles? Have you ever had loss of consciousness or fainted? Have you been hospitalized for a cardiac event?

Have you recently gained or lost weight? Are you experiencing chest pain? Do you have edema or swelling in your ankles?

Which components does the nurse assess during the musculoskeletal examination? Select all that apply. Mobility Bone disease Tendon injury Cartilage disorder Exercise level

Mobility Bone disease Tendon injury Exercise level

Which assessment techniques would the nurse use when assessing the musculoskeletal system? Select all that apply. Palpation Inspection Percussion Observation Auscultation

Palpation Inspection

In which areas would the nurse use a reflex hammer to assess for deep tendon reflexes? Select all that apply. Patellae Biceps Triceps Phalanges Achilles tendon

Patellae Biceps Triceps Achilles tendon

Which finding indicates a problem associated with bone loss, such as osteoporosis? Gross disfigurement Abnormal reflexes Postural abnormalities Decreased pulse strength

Postural abnormalities

Which components are included in the neurologic system? Select all that apply. Skull Brain Nerves Spinal cord Carotid artery

Brain Nerves Spinal cord

Match the type of neurologic examination to the appropriate description. Eye movements and pupillary reflex Sharp/dull discrimination or light touch Strength, coordination, and gait Level of consciousness and orientation Answer choices Cranial nerves Motor function Sensation Mental status

Eye movements and pupillary reflex Cranial nerves Sharp/dull discrimination or light touch Sensation Strength, coordination, and gait Motor function Level of consciousness and orientation Mental status

Which component of the focused neurologic examination addresses emotional state? Sensation Mental status Motor function Cranial nerves

Mental status

Which patient position enables the nurse to perform an examination of the gastrointestinal system? Sims Prone Supine Fowler

Supine

Place the components of the gastrointestinal examination in the correct order. Auscultation Inspection Palpation Percussion

Inspection Auscultation Palpation Percussion

Which unexpected findings from the abdominal assessment would the nurse document in the electronic health record and report to the health care provider? Select all that apply. Flat abdomen Visible protrusions Rebound tenderness Hyperactive bowel sounds Bowel sounds in all quadrants

Visible protrusions Rebound tenderness Hyperactive bowel sounds

Which priority action would the nurse take before beginning an examination of the breasts and genitals? Ensure proper positioning of the patient. Provide a quiet, calm environment. Ensure respect for the patient’s privacy. Provide education regarding self-examinations

Ensure respect for the patient’s privacy.

In which position would the nurse place the female patient to examine the female genitalia? Sims Supine Fowler Lithotomy

Lithotomy

Which member of the health care team can perform internal vaginal and prostate examinations? Registered nurse Health care provider Patient care technician Certified nursing assistant

Health care provider

In which order would the nurse perform an assessment of the integumentary system. Review the patient’s medical records for preexisting issues with skin, hair, or nails. Complete physical examination of the skin, hair, and nails. Interview the patient to complete the general survey, health history, and review of systems.

Review the patient’s medical records for preexisting issues with skin, hair, or nails. Interview the patient to complete the general survey, health history, and review of systems. Complete physical examination of the skin, hair, and nails.

Which components would the nurse assess during palpation of the skin? Select all that apply. Clubbing Swelling Skin texture Discoloration Skin temperature

Swelling Skin texture Skin temperature

When the nurse identifies clubbing of a patient’s nails, which type of medical condition would the nurse suspect as the cause? Cardiac Neurologic Gastrointestinal Musculoskeletal

Cardiac

Which part of the eye would the nurse palpate gently to assess for nodules or pain? Lens Eyelid Cornea Orbital bone

Eyelid

Which part of the nose would the nurse palpate to assess for swelling, drainage, and tenderness? Nostrils Mucosa Sinuses Septum

Sinuses

When examining the head and its associated structures, which unexpected findings would the nurse document? Select all that apply. Lumps Edema Lesions Symmetry Discoloration

When examining the head and its associated structures, which unexpected findings would the nurse document? Select all that apply. Lumps Edema Lesions Discoloration

Which techniques would the nurse utilize to auscultate the patient’s chest during the respiratory assessment? Select all that apply. Listen for a full respiratory cycle. Use a systematic pattern. Assess at least two lobes. Feel for depth of breathing. Listen for unexpected sounds.

Listen for a full respiratory cycle. Use a systematic pattern. Listen for unexpected sounds

Which aspects does the nurse assess while palpating the chest during the respiratory system assessment? Select all that apply. Respiratory rate Masses Skin moisture Front-to-back diameter Breathing effort

Masses Skin moisture

Which characteristic is the nurse assessing when placing thumbs on either side of the spine during the respiratory system assessment? Lung capacity Lung shape Respiratory rate Depth of respirations

Depth of respirations

Which additional body system would the nurse evaluate when assessing the cardiovascular and peripheral vascular systems? Respiratory Genitourinary Gastrointestinal Musculoskeletal

Respiratory

Which actions would the nurse implement during auscultation of the cardiovascular system? Select all that apply. Listen at all three valves Evaluate for symmetry Assess rate and rhythm Feel for quality of pulses Use both sides of stethoscope

Assess rate and rhythm Use both sides of stethoscope

Which aspect of cardiovascular function does the nurse assess when inspecting the skin and lower extremities? Apical pulse Peripheral pulses Peripheral perfusion Heart rhythm

Peripheral perfusion

Which action allows the nurse to focus questions about the musculoskeletal system during the health history interview? Review of health records Organization of equipment Analysis of the review of systems Completion of the physical examination

Review of health records

Which potential findings would the nurse assess during the palpation phase of the musculoskeletal examination? Select all that apply. Masses Crepitus Tenderness Deep tendon reflexes Postural abnormalities

Masses Crepitus Tenderness

Which physical assessment findings related to the musculoskeletal system would the nurse report to the health care provider? Select all that apply. Pain Lesions Absence of crepitus Abnormal posture or gait Presence of deep tendon reflexes

Pain Lesions Abnormal posture or gait

Which assessment technique would the nurse use during the neurologic assessment? Inspection Reflexology Percussion Auscultation

Inspection

Which nerve does the nurse assess when applying dull and sharp stimuli to different areas of the body? Motor nerve Cranial nerve Sensory nerve Accessory nerve

Sensory nerve

Which nerve does the nurse examine by evaluating eye movements and pupillary reflexes? Motor nerve Cranial nerve Sensory nerve Accessory nerve

Cranial nerve

Which assessment techniques would the nurse use during the abdominal assessment? Select all that apply. Palpation inspection Percussion Observation Auscultation

Palpation inspection Auscultation

The abdominal and gastrointestinal organs are assessed during the evaluation of which body systems? Select all that apply. Urinary Digestive Endocrine Circulatory Reproductive

Urinary Digestive

Which component of the gastrointestinal assessment does the nurse evaluate using the diaphragm of the stethoscope? Wheezes Blood flow Bowel sounds Breath sounds

Bowel sounds

Which findings would the nurse recognize as abnormal during assessment of the male genitalia? Select all that apply. Rashes Lesions Masses Dimpling Discharge

Rashes Lesions Masses Discharge

Which technique would the nurse use to palpate the breast tissue? Both hands Palm of one hand Two to three fingers Thumb and forefinger

Two to three fingers

During the breast and genital examination, which findings would the nurse document and report to the health care provider? Select all that apply. Lesions on the genitalia Presence of hemorrhoids Unusual odor or discharge Excoriation of the breast tissue Symmetry of the breast tissue

Lesions on the genitalia Presence of hemorrhoids Unusual odor or discharge Excoriation of the breast tissue

Which functions does the nurse complete during the second step of the Clinical Judgment Measurement Model? Select all that apply. Relate findings to potential disease processes. Examine subjective and objective patient cues. Interpret cues collected during the evaluation phase. Correlate patient cues to conditions by clustering data. Link cues from step one (Assessment) to step two (Recognize Cues).

Relate findings to potential disease processes. Examine subjective and objective patient cues. Correlate patient cues to conditions by clustering data.

Which questions help the nurse to cluster and analyze patient data during the second step of the Clinical Judgment Measurement Model? Select all that apply. Which patient findings fit together? Which conditions present with cues like the patient’s cues? What other information can help evaluate patient outcomes? Are there any findings or patient cues that seem contradictory? Which patient conditions are expected based on the medical diagnosis?

Which patient findings fit together? Which conditions present with cues like the patient’s cues? Are there any findings or patient cues that seem contradictory? Which patient conditions are expected based on the medical diagnosis?

Which outcome results from analysis of patient assessment data during the second step of the Clinical Judgment Measurement Model? A prioritized list of patient needs A single nursing diagnostic statement Nursing interventions to achieve patient goals Grouping of patient cues according to similarities

Grouping of patient cues according to similarities

Which labels describe a hypothesis? Select all that apply. Patient problem Objective patient cue Subjective patient cue Diagnosed medical condition Ailment the patient is at risk for developing

Patient problem Diagnosed medical condition Ailment the patient is at risk for developing

Place in order the actions the nurse takes when applying the Clinical Judgment Measurement Model to nursing practice. Recognize cues Form hypotheses Link cues Cluster cues

Recognize cues Cluster cues Link cues Form hypotheses

Which statement describes how nurses apply the International Classification for Nursing Practice (ICNP) terminology to the second step of the Clinical Judgment Measurement Model? Collect patient cues. Determine outcomes. Prioritize hypotheses. Select nursing diagnoses.

Select nursing diagnoses.

Which action is essential for the nurse to complete during step two of applying the Clinical Judgment Measurement Model to nursing practice? Recognize patient cues. Consider environmental factors. Cluster subjective and objective data. Generate solutions based on patient needs.

Cluster subjective and objective data.

When analyzing patient cues during the second step of the Clinical Judgment Measurement Model, which strategy provides meaning to cues and insight into the patient’s unique circumstances? Developing a nursing diagnosis Clustering similar data into groups Conducting a complete head-to-toe assessment Asking questions to identify patterns among collected cues

Asking questions to identify patterns among collected cues

Which concepts does the nurse apply when clustering patient data? Select all that apply. Anticipated findings Potential disease processes Prior patient care experiences Stages of growth and development Process for prioritization of hypotheses

Anticipated findings Potential disease processes Prior patient care experiences Stages of growth and development

Which types of factors influence the development of a hypothesis? Select all that apply. Risk Social Indirect Cultural Supportive

Risk Social Cultural

The nurse clustered the following patient cues during the assessment: Sharp pain in lower right abdomen, patient pain rating 9 on a 0-to-10 pain scale, and facial grimacing. Which hypothesis based on International Classification for Nursing Practice (ICNP) terminology can the nurse select when clustering the data? Acute Pain Constipation Abdominal Pain Risk for Vomiting

Abdominal Pain

Which statement describes why nurses identify supporting data for a hypothesis? Supporting data validates the patient’s plan of care. Identification of supporting data allows the nurse to individualize the plan of care. Documentation of supporting data allows the nurse to prioritize hypotheses. Supporting data provides consistency when planning care for patients experiencing similar conditions.

Identification of supporting data allows the nurse to individualize the plan of care.